A national depiction of children with return visits to the emergency department within 72 hours, 2001-2007

Evaluation of unplanned reattendances to the pediatric emergency department - a five-year study

BACKGROUND

Unplanned reattendances (UR) are an important quality indicator in the emergency department (ED). Understanding the risk factors associated with UR can aid clinicians in optimizing the allocation of time and resources, as well as targeted counselling for this specific group of patients. In this study, we aimed to compare patient characteristics between children who attended a pediatric emergency department (ED) with unplanned reattendances (UR) and those without UR. We also aimed to study the association between healthcare delivery factors such as timing of the attendance, patient load, changeover months for rotating junior doctors, presence of supervision, and rate of UR.

STUDY DESIGN

We performed a retrospective, single-center cohort study of patients < 18 years old who visited the ED between January 2018 and March 2023. UR was defined as a revisit within 72 h of the index ED visit. We collected data on demographics, attendance data and clinical characteristics. Logistic regression was performed for factors independently associated with UR, after adjusting for age, patient acuity, timing of attendance, presence of senior doctor supervision, rotation months for junior doctors, and diagnostic category.

RESULTS

Out of the 544,699 eligible children, 24,733 (4.5%) reattended the ED within 72 h, of which 10,915 (44.1%) of them were hospitalized on their reattendance visit. The independent factors associated with UR were young age (age < 3 years old: aOR 1.585 95%CI 1.481-1.698, p < 0.001), high acuity P2+ (aOR 1.398 95%CI 1.354-1.444, p < 0.001), attendance in the evening (aOR 1.086 95%CI 1.055-1.117, p < 0.001) and night (aOR 1.365 95%CI 1.314-1.417, p < 0.001), gastrointestinal diagnosis (aOR 1.528, CI 1.469-1.588; p < 0.001) and respiratory diagnosis (aOR 1.155, CI 1.121-1.189, p < 0.001).

CONCLUSIONS

We identified independent risk factors for UR that could guide resource allocation. Future studies should investigate if targeted interventions may reduce UR in these at-risk populations.

Development and Internal Validation of a Multivariable Prediction Model to Predict Repeat Attendances in the Pediatric Emergency Department: A Retrospective Cohort Study

OBJECTIVE

Unplanned reattendances to the pediatric emergency department (PED) occur commonly in clinical practice. Multiple factors influence the decision to return to care, and understanding risk factors may allow for better design of clinical services. We developed a clinical prediction model to predict return to the PED within 72 hours from the index visit.

METHODS

We retrospectively reviewed all attendances to the PED of Royal Manchester Children's Hospital between 2009 and 2019. Attendances were excluded if they were admitted to hospital, aged older than 16 years or died in the PED. Variables were collected from Electronic Health Records reflecting triage codes. Data were split temporally into a training (80%) set for model development and a test (20%) set for internal validation. We developed the prediction model using LASSO penalized logistic regression.

RESULTS

A total of 308,573 attendances were included in the study. There were 14,276 (4.63%) returns within 72 hours of index visit. The final model had an area under the receiver operating characteristic curve of 0.64 (95% confidence interval, 0.63-0.65) on temporal validation. The calibration of the model was good, although with some evidence of miscalibration at the high extremes of the risk distribution. After-visit diagnoses codes reflecting a nonspecific problem ("unwell child") were more common in children who went on to reattend.

CONCLUSIONS

We developed and internally validated a clinical prediction model for unplanned reattendance to the PED using routinely collected clinical data, including markers of socioeconomic deprivation. This model allows for easy identification of children at the greatest risk of return to PED.

Outcomes of Infants Who Are Febrile Aged 29-90 Days Discharged from the Emergency Department

OBJECTIVE

To evaluate the characteristics and outcomes of infants aged 29-90 days who are febrile discharged from the pediatric emergency department (ED).

STUDY DESIGN

This was a multicenter, retrospective cohort study of infants aged 29-90 days who visited any of the 7 Clalit Health Services pediatric EDs in Israel between January 1, 2019, and March 31, 2022. Infants who were febrile discharged from the ED after having blood and urine cultures taken were included. The primary outcome measure was the incidence of return visit (RV) to an ED. Secondary outcome measures were the incidence of invasive bacterial infection, urinary tract infection, pediatric intensive care unit admissions, and deaths. We assessed variables associated with the primary outcomes.

RESULTS

A total of 1647 infants were included. Their median (IQR) age at ED visit was 58.5 (47.7, 72.7) days, 53.1% were male. A total of 329 patients (20%) returned to the ED within 120 hours. Overall, 7.8% of discharged infants had a positive urine culture, 4 (0.2%) had a positive blood culture, and none had meningitis. One patient was admitted to the pediatric intensive care unit, and there was no death. Abnormal C-reactive protein was associated with RV among 61- to 90-day-old infants.

CONCLUSIONS

Infants aged 29-90 days who were febrile and discharged following a protocol-driven pathway from the pediatric ED had a relatively high RV rate. However, the rate of urinary tract infection was relatively low, and rate of invasive bacterial infection was extremely low. There were no deaths or serious sequelae.

The risk factors of the 72-h unscheduled return visit admission to emergency department in adults below 50 years old

BACKGROUND

An unscheduled return visit (URV) to the emergency department (ED) within 72-h is an indicator of ED performance. An unscheduled return revisit (URV) within 72-h was used to monitor adverse events and medical errors in a hospital quality improvement program. The study explores the potential factors that contribute to URV to the ED within 72-h and the unscheduled return revisit admission (URVA) in adults below 50 years old.

METHODS

The case-control study enrolled 9483 URV patients during 2015-2020 in National Cheng-Kung University Hospital. URVA and URV non-admission (URVNA) patients were analyzed. The Gini impurity index was calculated by decision tree (DT) to split the variables capable of partitioning the groups into URVA and URVNA. Logistic regression is applied to calculate the odds ratio (OR) of candidate variables. The α level was set at 0.05.

RESULTS

Among patients under the age of 50, the percentage of females in URVNA was 55.05%, while in URVA it was 53.25%. Furthermore, the average age of URVA patients was 38.20 ± 8.10, which is higher than the average age of 35.19 ± 8.65 observed in URVNA. The Charlson Comorbidity Index (CCI) of the URVA patients (1.59 ± 1.00) was significantly higher than that of the URVNA patients (1.22 ± 0.64). The diastolic blood pressure (DBP) of the URVA patients was 85.29 ± 16.22, which was lower than that of the URVNA (82.89 ± 17.29). Severe triage of URVA patients is 21.1%, which is higher than the 9.7% of URVNA patients. The decision tree suggests that the factors associated with URVA are "severe triage," "CCI higher than 2," "DBP less than 86.5 mmHg," and "age older than 34 years". These risk factors were verified by logistic regression and the OR of CCI was 2.42 (1.50-3.90), the OR of age was 1.84 (1.50-2.27), the OR of DBP less than 86.5 was 0.71 (0.58-0.86), and the OR of severe triage was 2.35 (1.83-3.03).

CONCLUSIONS

The results provide physicians with a reference for discharging patients and could help ED physicians reduce the cognitive burden associated with the diagnostic errors and stress.

Early reattenders to the paediatric emergency department: A prospective cohort study and multivariate analysis

AIMS

The rate of unplanned reattendances is used as an indicator of the quality of care delivered in a paediatric emergency department (PED). With early reattendance in the UK well above the national target of 1-5%, we aimed to identify the factors which predict unplanned early reattendance to the PED.

METHODS

This is a prospective, single-centre cohort study undertaken over 12 months. Data were collected on all patients who reattended the PED within 7 days of their initial visit as well as for a comparative cohort of patients with no visit in the preceding or subsequent 7 days. Multiple patient and departmental variables were recorded and analysed using a multivariate regression model.

RESULTS

There were a total of 19 420 index visits to the PED, of which 1461 patients had an unscheduled reattendance within 7 days - a rate of 7.5%. Factors associated with unplanned but related reattendance include young age and diagnosis with a respiratory or other medical illness. Interestingly, the grade of clinician appeared to be relevant with patients seen by junior members of the medical team less likely to reattend. Acuity of illness was not a significant factor. A substantial number of unplanned early reattenders (36.3%) would have been missed had a time period of 72 h been used rather than 7 days.

CONCLUSIONS

This study identifies the typical patient who will have an unplanned, related early reattendance to a PED. This study also supports the use of a 7-day time period when using early reattendance as a performance indicator.

Pediatric Return Visits to the Emergency Department: The Time to Return Curve

OBJECTIVE

Although 72-hour return visits are a frequently reported metric for pediatric patients discharged from the emergency department (ED), the basis for this metric is not established. Our objective was to statistically derive a cutoff time point for the characterization of pediatric return visits.

METHODS

We performed a retrospective cohort study using data of patients discharged from any of 44 pediatric EDs. We selected the first encounter per patient from January 1 to December 31, 2019, as the index encounter and included the first return visit within 30 days. We constructed a cumulative hazard curve to characterize the timing of return visits and constructed a multivariable adaptive regression spline model to identify a hinge point in return visit presentations. We identified the association between admission for early return visits and admission for late return visits using generalized linear mixed modeling.

RESULTS

Of 1,986,778 index ED discharges, 193,605 (9.7%) ED return visits were included. A double-exponential decay model demonstrated superior fit compared with a single exponential model ( P < 0.0001). Multivariable adaptive regression spline modeling identified a hinge at 7 days. When comparing proportions of return visits leading to hospitalization between early (23.8%) and late (15.1%) return visits, early visits (≤7 days) had higher adjusted odds of hospital admission (adjusted odds ratio, 1.73; 95% confidence interval, 1.69-1.77) relative to late return visits (>7 days). Findings were similar in sensitivity analyses within age subgroups, Census region, and in which the diagnosis (using the Diagnosis and Grouping System) was the same between the index and return visit. Among return visits that occurred within 7 days of the index visit, 46.3% had the same diagnosis grouping in both visits.

CONCLUSIONS

An empirically derived 7-day cutoff may be more appropriate for characterization of pediatric return visits to the ED. Encounters after this period had lower adjusted odds of admission.

A Comparison of Emergency Department Revisit Rates of Pediatric Patients between Pre-COVID-19 and COVID-19 Periods

Unscheduled revisits to emergency departments (EDs) are important because they indicate the quality of emergency care. However, the characteristics of pediatric patients visiting EDs changed during the coronavirus disease (COVID-19) pandemic, and these changes may have affected their revisit patterns. Therefore, we aimed to compare the ED revisit patterns of pediatric patients between the pre-COVID-19 and COVID-19 periods. This retrospective multicenter study included patients aged below 18 years who visited the ED in the pre-COVID-19 and COVID-19 periods. ED revisit rates were analyzed using five age groups and three visit-revisit intervals. In the pre-COVID-19 period, the revisit rates decreased with increasing age. In the COVID-19 period, the revisit rates were the lowest for the group aged 4–6 years, and the rates increased for those aged ≥7 years. In conclusion, there were changes in the patterns of revisit rates of pediatric patients according to age between the pre-COVID-19 and COVID-19 periods. Therefore, it is necessary to identify the reasons for revisits according to age and establish strategies to reduce the revisit rates of pediatric patients.

Racial and ethnic differences in low-value pediatric emergency care

BACKGROUND

Disparities in health care quality frequently focus on underuse. We evaluated racial/ethnic differences in low-value services delivered in the pediatric emergency department (ED).

METHODS

We performed a retrospective cross-sectional study of low-value services in children discharged from 39 pediatric EDs from January 2018 to December 2019 using the Pediatric Hospital Information System. Our primary outcome was receipt of one of 12 low-value services across nine conditions, including chest radiography in asthma and bronchiolitis; beta-agonist and corticosteroids in bronchiolitis; laboratory testing and neuroimaging in febrile seizure; neuroimaging in afebrile seizure; head injury and headache; and any imaging in sinusitis, constipation, and facial trauma. We analyzed the association of race/ethnicity on receipt of low-value services using generalized linear mixed models adjusted for age, sex, weekend, hour of presentation, payment, year, household income, and distance from hospital.

RESULTS

We included 4,676,802 patients. Compared with non-Hispanic White (NHW) patients, non-Hispanic Black (NHB) and Hispanic patients had lower adjusted odds (aOR [95% confidence interval]) of receiving imaging for asthma (0.60 [0.56 to 0.63] NHB; 0.84 [0.79 to 0.89] Hispanic), bronchiolitis (0.84 [0.79 to 0.89] NHB; 0.93 [0.88 to 0.99] Hispanic), head injury (0.84 [0.80 to 0.88] NHB; 0.80 [0.76 to 0.84] Hispanic), headache (0.67 [0.63 to 0.72] NHB; 0.83 [0.78 to 0.88] Hispanic), and constipation (0.71 [0.67 to 0.74] NHB; 0.76 [0.72 to 0.80] Hispanic). NHB patients had lower odds (95% CI) of receiving imaging for afebrile seizures (0.89 [0.8 to 1.0]) and facial trauma (0.69 [0.60 to 0.80]). Hispanic patients had lower odds (95% CI) of imaging (0.57 [0.36 to 0.90]) and blood testing (0.82 [0.69 to 0.98]) for febrile seizures. NHB patients had higher odds (95% CI) of receiving steroids (1.11 [1.00 to 1.21]) and beta-agonists (1.38 [1.24 to 1.54]) for bronchiolitis compared with NHW patients.

CONCLUSIONS

NHW patients more frequently receive low-value imaging while NHB patients more frequently receive low-value medications for bronchiolitis. Our study demonstrates the differences in care across race and ethnicity extend to many services, including those of low value. These findings highlight the importance of greater understanding of the complex interaction of race and ethnicity with clinical practice.

Evaluation of Unscheduled Return Visits to the Pediatric Emergency Department and Risk Factors for Admission After Return Visit

OBJECTIVE

Unscheduled return visits to the emergency department (unscheduled RTED) increase both the workload and overcrowding in the emergency department. The aim in the present study is to identify the patient groups that require more careful and closer follow-up to reduce the rates of unscheduled RTED and hospital admissions after a return visit.

METHODS

Among the patients admitted to the emergency department of our hospital between 2016 and 2017, those who made an unscheduled RTED within 72 hours after their first visit to the emergency department were evaluated retrospectively.

RESULTS

Of the 137,787 eligible children, 3294 (2.8%) made unscheduled RTEDs within 72 hours. The median age was 28 months, and 1848 (57.6%) were male patients. The admission rate at the return visit was significantly higher among children younger than 2 years, in the patients presenting with respiratory complaints and severe acute conditions, and in those who presented to the emergency department for the first time during the department's busiest hours. The risk of admission upon a return visit to the emergency department was 2.7 times higher in the male sex, 5.4 times higher in children younger than 2 years, 5.9 times higher in patients with respiratory complaints, 4.9 times higher in patients with gastrointestinal tract complaints, and 27,000 times higher in patients with severe acute conditions.

CONCLUSIONS

Unscheduled RTED and hospitalization rates can be reduced with more careful evaluation of young children, patients with respiratory and gastrointestinal complaints and those who apply during emergency department busiest hours.

Pediatric Emergency Department Return Visits Within 72 Hours: Caregivers' Motives and Analysis of Ethnic and Primary Language Disparities

OBJECTIVES

In the United States, approximately 2.2% to 5% of children discharged from the emergency department (ED) return within 72 hours. There is limited literature examining caregivers' reasons for return to the ED, and none among Hispanics and Spanish-speaking caregivers. We sought to examine why caregivers of pediatric patients return to the ED within 72 hours of a prior ED visit, and assess roles of ethnicity and primary language.

METHODS

A previously validated survey was prospectively administered to caregivers returning to the ED within 72 hours of discharge at a freestanding, tertiary care, children's hospital over a 7-month period. Reasons for return to the ED, previous ED discharge processes, and events since discharge were summarized according to Hispanic ethnicity, and English or Spanish language preference, and compared using the Fisher exact test.

RESULTS

Among 499 caregiver surveys analyzed, caregivers returned mostly because of no symptom improvement (57.5%) and worsening condition (35.5%), with no statistically significant differences between Hispanic/non-Hispanic ethnicity, or English/Spanish preference. Most (85.2%) caregivers recalled reasons to return to the ED. Recall of expected duration until symptom improvement was significantly higher among Hispanic (60.4%) versus non-Hispanic (52.1%) (P = 0.003), and for Spanish- (68.9%) versus English-speaking (54.6%) (P = 0.04), caregivers.

CONCLUSIONS

Most caregivers returned to the ED because their child's condition was not better or had worsened. Ethnicity and language were not associated with variations in reasons for return. Non-Hispanic and English-speaking caregivers were less likely to recall being informed of time to improvement and may require additional intervention.

Racial and Ethnic Differences in Prescription Filling After Discharge From an Urban Pediatric Emergency Department

OBJECTIVE

The aim of this study was to measure racial/ethnic differences in prescription filling among children prescribed with outpatient antibiotics from the emergency department (ED).

METHODS

This study is a retrospective cohort study of ED visits among children (0-21 years) from January 1 to March 31, 2018, during which oral antibiotics were prescribed. We measured the proportion of filled prescriptions in aggregate and by patient race/ethnicity. We performed multivariable logistic regression to identify patient and visit-level factors associated with prescription filling. Secondarily, we measured differences in ED revisits by prescription filling.

RESULTS

A total of 2881 participants were enrolled. A total of 66.3% (95% confidence interval, 64.5-68.0) of prescriptions were filled. Prescription filling varied by race/ethnicity; these are as follows: 77.3% non-Hispanic (NH) white, 73.5% NH black, 51.5% Hispanic, and 51.3% others (P < 0.0001). After adjustment for patient and visit-level characteristics, Hispanic children (adjusted odds ratio [aOR], 0.5 [0.3-0.9]) and children of other racial/ethnic groups (aOR, 0.5 [0.3-0.8]) had lower odds of prescription filling in comparison to NH white children. Interpreter use (aOR, 0.5 [0.4-0.6]) and uninsured status (aOR, 0.4 [0.3-0.5]) were additional independent risk factors associated with lower odds of prescription filling. There were no differences in the 72-hour revisit rates between those who filled their prescriptions and those who did not.

CONCLUSIONS

A third of antibiotic prescriptions for bacterial infections in the ED are unfilled. Hispanic children and children of other racial/ethnic groups have lower rates of prescription filling compared with NH white children. Interpreter use and uninsured status also have lower rates of prescription filling. Barriers to prescription filling should be explored further to help reduce racial and ethnic disparities in the provision of health care.

Evaluation of advanced practice provider related return visits to a pediatric emergency department and their outcomes

BACKGROUND

While multiple studies have evaluated physician-related return visits (RVs) to a pediatric emergency department (PED) limited data exists for Advanced Practice Provider (APP)-related RVs, hence our study aimed to evaluate APP-related RVs and their outcomes in a PED.

METHODS

We conducted a retrospective review of 72-h RVs where clinical care was independently provided by an APP during the index visit from January 2018 to December 2019. We extracted patient demographics, index and return visits' characteristics and outcomes. Reasons for RVs were categorized as progression of illness, medication-related, callbacks and others. Index visits were assessed for any diagnostic errors; impact of which to the patient was classified as none, minor or major.

RESULTS

Our APP-related RV rate was 2.1% (653/30,328). 462 eligible RVs were included in the final analysis. Majority of RVs were for medical reasons (n = 442, 95.7%); lower acuity (Emergency Severity Index ≥3, n = 426, 92.2%); due to persistence/progression of illness (n = 403; 87.2%) with viral illness being the common diagnosis (n = 159; 34.4%). 12 (2.6%) RVs were secondary to callbacks (8 radiology callbacks; 4 false positive blood cultures). Diagnostic errors were noted in 14 (3%) encounters of which 3 resulted in a major impact; radiological (7 fractures) and ophthalmological (2 corneal abrasions and 2 foreign bodies) misses constituted the majority of these.

CONCLUSIONS

APP-related RVs for low acuity medical patients remain low and are associated with good outcomes. Diagnostic errors account for a minority of these RVs. Focused interventions targeting provider errors can further decrease these RVs.

Evaluation of the Pattern of Use of a Pediatric Emergency Department in Italy

OBJECTIVES

The aim of this study was to evaluate access to a pediatric emergency department (PED) in a large hospital, in particular to estimate the prevalence of potentially avoidable accesses and the characteristics of return visits.

METHODS

Clinical health records from the PED of San Gerardo Hospital, Monza, Italy, were retrospectively reviewed. The study population was composed of subjects younger than 18 years who attended the PED during the period from October 1, 2017, to November 30, 2017.Accesses were defined nonurgent if characterized by white or green triage codes and patient's discharge as the outcome and were defined potentially avoidable if nonurgent and with no diagnostic/therapeutic procedures performed except a visit by the ED pediatrician.Return visits were defined as accesses that occurred within 72 hours of the first index visit.

RESULTS

A total of 2064 children and adolescents younger than 18 years had at least 1 ED attendance between October and November 2017, for a total of 2364 accesses.The most frequent diagnoses were upper respiratory tract infections (29.5% of accesses), followed by gastroenteritis (7.0%) and abdominal pain (7.0%). In all, 1810 accesses (88%) were classified as "nonurgent," and 1228 (60%) potentially avoidable, 373 of which were probably avoidable because they occurred when the primary care physician was available.The number of return visits was 98 (5% of the accesses): 74 were nonurgent, 31 of which potentially avoidable. On 17 occasions, both index and return visits were potentially avoidable.

CONCLUSIONS

We confirm that most of the accesses to a PED are nonurgent and potentially avoidable. Interventions are needed to improve the appropriateness of use of emergency services.

A Framework for Quality Assurance of Pediatric Revisits to the Emergency Department

BACKGROUND

Emergency department return visits significantly impact medical costs and patient flow. A comprehensive approach to understanding these patients is required to identify deficits in care, system level inefficiencies, and improve diagnosis specific management protocols. We aimed to identify factors needed to successfully analyze return visits to explore root causes leading to unplanned returns and inform system-level improvements.

METHODS

A multidisciplinary committee collaborated to develop a quality review process for return visits within 72 hours to our pediatric emergency department that were then subsequently admitted to the hospital. The committee developed methodology and a web-based tool for chart review and analysis.

RESULTS

Of 197,076 ED visits (159,164 discharged at initial visit), 5390 (3.4%) patients were discharged and represented to the ED within 72 hours and 1658 (1.0%) of those resulted in admission. Using defined criteria, approximately one third (n = 564) of revisits with admission were identified for chart review. Reason for revisit included natural progression of disease (67.6%), new condition or problem (11.2%), diagnostic error (6.9%), and scheduled or planned readmissions (3.5%). All diagnostic errors had not been previously identified by ED leadership. Of the reviewed cases, most were not preventable (84.0%); however, a number of system-level actions resulted from discussion of the potentially preventable revisits.

CONCLUSIONS

Seventy-two-hour ED revisits were efficiently and systematically categorized with determination of root causes and preventability. This process resulted in shared provider-level feedback, identifying trends in revisits, and implementation of system-level actions, therefore, encouraging other institutions to adopt a similar process.

Unplanned Return Visits to a Pediatric Emergency Department

OBJECTIVES

Unplanned return visits (URVs) to emergency departments (EDs) account internationally for 2.5% to 5.2% of all consultations. ED crowding is an increasing challenge, and URVs seem to contribute to this problem. This study aimed to assess factors for URVs at the ED of a tertiary children's hospital to analyze if they are jointly responsible for the steadily rising amount of treated patients.

METHODS

All patients with an URV to a pediatric ED in Switzerland between January and December 2013 were included in the study. Data were taken retrospectively from the electronic patient files, and different variables were defined and analyzed.

RESULTS

URVs occurred at an incidence of 4.6%, and mostly concerned infants and toddlers (46%). URVs were independent of weekdays and mostly occurred between 10 am and 10 pm. In 84.2% of the cases, the URVs were judged as unnecessary, and in 15.8%, a hospitalization was indicated, mainly for children with a worsening respiratory illness.

CONCLUSIONS

The occurrence of URVs in our ED was within the incidence reported in the literature. While URVs lead to hospitalization in some patients, the majority of URVs were unnecessary from a medical point of view. These results indicate that a correct evaluation of the child's health state by parents is often challenging and requires repeated medical attendance following a first ED visit, especially in infants with airway diseases and infections. Intensive counseling and scheduled short-term follow-up consultation at the pediatrician's office could prevent URVs to the ED.

Association of limited English proficiency and increased pediatric emergency department revisits

OBJECTIVE

Limited English proficiency (LEP) is a risk factor for health care inequity and an important focus for improving communication and care quality. This study examines the association between LEP and pediatric emergency department (ED) revisits.

METHODS

This was a retrospective, cross-sectional study of patients 0 to 21 years old discharged home after an initial visit from an academic, tertiary care pediatric ED from January 1, 2017, to June 30, 2018. We calculated rates of ED revisits within 72 h resulting in discharge or hospitalization and assessed rate differences between LEP and English-proficient (EP) patients. Multivariable logistic regression models examined the association between revisits and LEP status controlling for age, race, ethnicity, triage acuity, clinical complexity, and ED arrival time. Sensitivity models including insurance were also conducted.

RESULTS

There were 63,601 index visits in the study period; 12,986 (20%) were by patients with LEP. There were 2,387 (3.8%) revisits within 72 h of initial ED visit. Among LEP and EP patient visits, there were 4.53 and 3.55 revisits/100 initial ED visits, respectively (rate difference = 0.97, 95% confidence interval [CI] = 0.58 to 1.37). In the multivariable analyses, LEP was associated with increased odds of revisits resulting in discharge (odds ratio [OR] = 1.15, 95% CI = 1.01 to 1.30) and in hospitalization (OR = 1.28, 95% CI = 1.03 to 1.58). Sensitivity analyses additionally adjusting for insurance status attenuated these results.

CONCLUSIONS

These results suggest that LEP was associated with increased pediatric ED revisits. Improved understanding of language barrier effects on clinical care is important for decreasing health care disparities in the ED.

A clinical prediction model to identify children at risk for revisits with serious illness to the emergency department: A prospective multicentre observational study

BACKGROUND

To develop a clinical prediction model to identify children at risk for revisits with serious illness to the emergency department.

METHODS AND FINDINGS

A secondary analysis of a prospective multicentre observational study in five European EDs (the TRIAGE study), including consecutive children aged <16 years who were discharged following their initial ED visit ('index' visit), in 2012-2015. Standardised data on patient characteristics, Manchester Triage System urgency classification, vital signs, clinical interventions and procedures were collected. The outcome measure was serious illness defined as hospital admission or PICU admission or death in ED after an unplanned revisit within 7 days of the index visit. Prediction models were developed using multivariable logistic regression using characteristics of the index visit to predict the likelihood of a revisit with a serious illness. The clinical model included day and time of presentation, season, age, gender, presenting problem, triage urgency, and vital signs. An extended model added laboratory investigations, imaging, and intravenous medications. Cross validation between the five sites was performed, and discrimination and calibration were assessed using random effects models. A digital calculator was constructed for clinical implementation. 7,891 children out of 98,561 children had a revisit to the ED (8.0%), of whom 1,026 children (1.0%) returned to the ED with a serious illness. Rates of revisits with serious illness varied between the hospitals (range 0.7-2.2%). The clinical model had a summary Area under the operating curve (AUC) of 0.70 (95% CI 0.65-0.74) and summary calibration slope of 0.83 (95% CI 0.67-0.99). 4,433 children (5%) had a risk of > = 3%, which was useful for ruling in a revisit with serious illness, with positive likelihood ratio 4.41 (95% CI 3.87-5.01) and specificity 0.96 (95% CI 0.95-0.96). 37,546 (39%) had a risk <0.5%, which was useful for ruling out a revisit with serious illness (negative likelihood ratio 0.30 (95% CI 0.25-0.35), sensitivity 0.88 (95% CI 0.86-0.90)). The extended model had an improved summary AUC of 0.71 (95% CI 0.68-0.75) and summary calibration slope of 0.84 (95% CI 0.71-0.97). As study limitations, variables on ethnicity and social deprivation could not be included, and only return visits to the original hospital and not to those of surrounding hospitals were recorded.

CONCLUSION

We developed a prediction model and a digital calculator which can aid physicians identifying those children at highest and lowest risks for developing a serious illness after initial discharge from the ED, allowing for more targeted safety netting advice and follow-up.

Missed intracranial injuries are rare in emergency departments using the PECARN head injury decision rules

PURPOSE

The PECARN head trauma (HT) prediction rules have been developed to guide computed tomography-related decision-making for children with minor HT (mHT). There are currently limited data on the rate of unscheduled revisits to emergency departments (EDs), and initially missed intracranial injuries, in children with mHT initially assessed using the PECARN rules. This study aimed to fill this gap in knowledge.

METHODS

Clinical charts of children assessed for mHT over a 5-year period at two EDs that implemented the PECARN rules in Italy and France were reviewed retrospectively. Children who returned to EDs for mHT-related, or potentially related complaints, within 1 month of initial assessment were included.

RESULTS

The total number of children with mHT presenting for the first time to the EDs of both sites was 11,749. Overall, 180 (1.5%) unscheduled revisits to the EDs occurred for mHT-related or potentially related complaints. Twenty-three of these 180 patients underwent neuroimaging, and seven had an intracranial injury (including one ischemic stroke). Of these, three were hospitalized and none needed neurosurgery or intensive care.

CONCLUSION

Unscheduled revisits for mHT in EDs using the PECARN rules were very uncommon. Initially missed intracranial injuries were rare, and none needed neurosurgery or intensive care.

Frequency, Causes, and Outcomes of Return Visits to the Emergency Department Within 72 Hours: A Retrospective Observational Study

Background

Emergency departments (EDs) serve as an accessible gateway to healthcare system wherein numerous patients consider it a prime choice for medical complaints. Frequency of ED revisits, causes, and its burden are necessary to assess quality of care provided to patients and identify factors that leads to revisit.

Patients and Methods

Electronic and printed medical records of all patients who revisited ED from January to May 2016 within 72 hours of initial visit were reviewed. Patients’ cause of revisit were classified to three categories: patient-, physician- and system-related factors. Common complaints that require revisits were also collected. Descriptive analysis was performed and categorical variables were represented by the frequency; percentages and continuous variables were presented as median, and range if data did not follow normal distribution.

Results

Of the 79,279 patients who visited ED during the study period, 1.3% (1000) patients revisited within 72 hours; 51.3% (n=513) were males, with a mean age of 31.5 years (SD=17.7 years) where majority (57.1%) had no comorbidity recorded. The most attributed factors for revisit were as follows: patient-related causes 635 patients (63.5%), physician-related factors 167 patients (16.7%), and system-related factors 42 patients (4.2%); 15.6% were found not related to the initial visit. Recurrence of the same complaint was the highest among patient-related factors (80.5%), inadequate management and no improvement of symptoms in 71.3% among the physician-related factors. The most common ED revisit complaint was fever 29.1% (n=291). Outcomes of the revisit were mainly patient discharge 96.7% (n=967), admission 1.2% (n=12) and death in 0.2% (n=2).

Conclusion

Recurrence of the same complaint with no symptoms improvement and suboptimal management of physicians contributed to most of the ED revisits within 72 hours. Encouraging physicians to provide clear instructions in educating patients on discharge regarding disease progression and its red flags as to when a return to ED, might help in reducing revisit rate.

Abnormal Vital Sign Recognition and Provider Notification in the Pediatric Emergency Department

INTRODUCTION

Vital signs measurements aid in the early identification of patients at risk of clinical deterioration and determining the severity of illness. Health care providers rely on registered nurses to document vital signs and communicate abnormalities. The purpose of this project was to improve the provider notification process regarding abnormal vital signs in a pediatric emergency department.

METHOD

A best practice advisory (BPA) was piloted by the advanced practice providers in the pediatric emergency department. To evaluate the effects of the BPA, a mixed-methods study was employed.

RESULTS

Implementation of the BPA improved the provider notification process and enhanced clinical decision making. The percentage of patients discharged home with abnormal respiratory rates (10.9% vs. 5.9%, p = .31), abnormal temperatures (15.6% vs. 7.5%, p = .14), and abnormal heart rates (25% vs. 11.9%, p = .11) improved.

DISCUSSION

Creation and implementation of the BPA improved the abnormal vital sign communication process to providers at this single institution.

A Nested Mixed Effects Multicenter Model Examining the Risk Factors for Pediatric Trauma Return Visits Within 72 Hours

BACKGROUND

Return visits within 72 h are an important metric in evaluating the performance of emergency rooms. This has not been well studied in the pediatric trauma population. We sought to determine novel risk factors for return visits to the emergency department (ED) after trauma that may assist in identifying patients most at risk of revisit.

METHODS

We used the Cerner Health Facts Database to retrieve data from 34 EDs across the United States that care for pediatric trauma patients aged <15 y. The data consist of 610,845 patients and 816,571 ED encounters. We retrieved variables encompassing demographics, payor, current and past health care resource utilization, trauma diagnoses, other diagnoses/comorbidities, medications, and surgical procedures. We built a nested mixed effects logistic regression model to provide statistical inference on the return visits.

RESULTS

Traumas resulting from burns and corrosion, injuries to the shoulder and arms, injuries to the hip and legs, and trauma to the head and neck are all associated with increased odds of returning to the ED. Patients suffering from poisoning relating to drugs and other biological substances and patients with trauma to multiple body regions have reduced odds of returning to the ED. Longer ED length of stay and prior health care utilization (ED or inpatient) are associated with increased odds of a return visit. The sex of the patient and payor had a statistically significant effect on the risk of a return visit to the ED within 72 h of discharge.

CONCLUSIONS

Certain traumas expose patients to an increased risk for return visits to the ED and, as a result, provide opportunity for improved quality of care. Targeted interventions that include education, observation holds, or a decision to hospitalize instead of discharge home may help improve patient outcomes and decrease the rate of ED returns.

LEVEL OF EVIDENCE

III (Prognostic and Epidemiology).

Outpatient Parenteral Antimicrobial Therapy and Judicious Use of Pediatric Emergency Resources

BACKGROUND

Pediatric returns to the emergency department (RTED) vary between 3% and 13% of the total ED volume of visits. However, the incidence and contribution of scheduled RTED on pediatric emergency department (PED) utilization is less clear. Antimicrobial stewardship programs on inpatient wards have been shown to improve judicious use of outpatient parenteral antimicrobial therapy (OPAT) in upon discharge. The implementation of such programs in PEDs has yet to be reported. The objectives of this study are to quantify the burden of scheduled RTED for OPAT on PED utilization and to examine how frequently OPAT use are supported by published practice standards for 3 common pediatric infections-cellulitis, pneumonia, and urinary tract infections.

METHODS

We conducted a single-center retrospective cohort study of all visits made to the British Columbia Children's Hospital PED from May 1, 2012, to April 30, 2013. We identified scheduled RTEDs and characterized those associated with OPAT use with regard to their measures of PED utilization and clinical features.

RESULTS

Of 3904 RTED visits, 1310 (33.6%) were scheduled, of which 1029 were OPAT related. Among the latter, 749 RTEDs (69%) were for cellulitis, pneumonia, or urinary tract infections. The median length of stay for OPAT-related RTEDs was 2.0 hours. For 75 (24%) of 317 index visits and 213 (28%) of 749 subsequent RTEDs, oral antibiotic therapy would have been an appropriate option and OPAT could have been avoided.

CONCLUSIONS

Our findings suggest that OPAT poses a sizable burden on PED utilization, with a proportion of them potentially preventable.

Revisits, readmissions, and outcomes for pediatric traumatic brain injury in California, 2005-2014

Long-term outcomes related to emergency department revisit, hospital readmission, and all-cause mortality, have not been well characterized across the spectrum of pediatric traumatic brain injury (TBI). We evaluated emergency department visit outcomes up to 1 year after pediatric TBI, in comparison to a referent group of trauma patients without TBI. We performed a longitudinal, retrospective study of all pediatric trauma patients who presented to emergency departments and hospitals in California from 2005 to 2014. We compared emergency department visits, dispositions, revisits, readmissions, and mortality in pediatric trauma patients with a TBI diagnosis to those without TBI (Other Trauma patients). We identified 208,222 pediatric patients with an index diagnosis of TBI and 1,314,064 patients with an index diagnosis of Other Trauma. Population growth adjusted TBI visits increased by 5.6% while those for Other Trauma decreased by 40.7%. The majority of patients were discharged from the emergency department on their first visit (93.2% for traumatic brain injury vs. 96.5% for Other Trauma). A greater proportion of TBI patients revisited the emergency department (33.4% vs. 3.0%) or were readmitted to the hospital (0.9% vs. 0.04%) at least once within a year of discharge. The health burden within a year after a pediatric TBI visit is considerable and is greater than that of non-TBI trauma. These data suggest that outpatient strategies to monitor for short-term and longer-term sequelae after pediatric TBI are needed to improve patient outcomes, lessen the burden on families, and more appropriately allocate resources in the healthcare system.

ICU admission following an unscheduled return visit to the pediatric emergency department within 72 hours

INTRODUCTION

The purpose of this study was to describe the demographic characteristics and prognosis of children admitted to the intensive care unit (ICU) after a pediatric emergency department (PED) return visit within 72 h.

METHOD

We conducted this retrospective study from 2010 to 2016 in the PED of a tertiary medical center in Taiwan and included patients under the age of 18 years old admitted to the ICU after a PED return visit within 72 h. Clinical characteristics were collected to perform demographic analysis. Pediatric patients who were admitted to the ICU on an initial visit were also enrolled as a comparison group for outcome analysis, including mortality, ventilator use, and length of hospital stay.

RESULTS

We included a total of 136 patients in this study. Their mean age was 3.3 years old, 65.4% were male, and 36.0% had Chronic Health Condition (CHC). Disease-related return (73.5%) was by far the most common reason for return. Compared to those admitted on an initial PED visit, clinical characteristics, including vital signs at triage and laboratory tests on return visit with ICU admission, demonstrated no significant differences. Regarding prognosis, ICU admission on return visit has a higher likelihood of ventilator use (aOR:2.117, 95%CI 1.021~4.387), but was not associated with increased mortality (aOR:0.658, 95%CI 0.150~2.882) or LOHS (OR:-1.853, 95%CI -4.045~0.339).

CONCLUSION

Patients who were admitted to the ICU on return PED visits were associated with an increased risk of ventilator use but not mortality or LOHS compared to those admitted on an initial visit.

Hospital readmissions in paediatric trauma patients: A 10-year Australian review

AIM

Readmission of paediatric trauma patients is associated with increased hospital length of stay, additional operative procedures and significant costs to the health-care system. The rates and causes of readmission of paediatric trauma patients are not well reported outside of the USA or single centres. This nation-wide study is the first in Australia to examine the readmission rates, costs and characteristics of Australian paediatric trauma patients.

METHODS

This was a retrospective examination of linked hospitalisation and mortality data for injured children aged 16 or younger from 1 July 2001 to 30 June 2012, readmitted to hospital within 28 days of discharge. Data including injury severity, nature of injury, episodes of care and costs were extracted from hospitalisation data.

RESULTS

There were 37 603 injury children aged ≤16 years readmitted to hospital within 28 days during the 10-year period, a readmission rate of 5.5%. The most common principal injury requiring readmission was fracture (52.6%) and burns (19.3%). A total of 66% of all patients had a readmission diagnosis of injury, complication of their initial injury or complication of surgical and medical care; 30% were readmitted for a specific procedure or follow-up care. The total cost of readmissions was AU$108 million.

CONCLUSIONS

Hospital readmission rates of paediatric trauma patients in Australia are due to injury or a complication of injury and are associated with significant costs. Early identification of at-risk patients and the prevention of complications are needed to prevent the ongoing burden of readmission.

An Innovative Model to Predict Pediatric Emergency Department Return Visits

OBJECTIVES

Return visit (RV) to the emergency department (ED) is considered a benchmarking clinical indicator for health care quality. The purpose of this study was to develop a predictive model for early readmission risk in pediatric EDs comparing the performances of 2 learning machine algorithms.

METHODS

A retrospective study based on all children younger than 15 years spontaneously returning within 120 hours after discharge was conducted in an Italian university children's hospital between October 2012 and April 2013. Two predictive models, artificial neural network (ANN) and classification tree (CT), were used. Accuracy, specificity, and sensitivity were assessed.

RESULTS

A total of 28,341 patient records were evaluated. Among them, 626 patients returned to the ED within 120 hours after their initial visit. Comparing ANN and CT, our analysis has shown that CT is the best model to predict RVs. The CT model showed an overall accuracy of 81%, slightly lower than the one achieved by the ANN (91.3%), but CT outperformed ANN with regard to sensitivity (79.8% vs 6.9%, respectively). The specificity was similar for the 2 models (CT, 97% vs ANN, 98.3%). In addition, the time of arrival and discharge along with the priority code assigned in triage, age, and diagnosis play a pivotal role to identify patients at high risk of RVs.

CONCLUSIONS

These models provide a promising predictive tool for supporting the ED staff in preventing unnecessary RVs.

Management practice-related and modifiable factors associated with paediatric emergency return visits

OBJECTIVES

We explored practice-related factors associated with preventable unscheduled return visits to an emergency department (RTED).

METHODS

We conducted a retrospective cohort study, using standardized review of health records. We included all visits with at least one RTED within 7 days of the index visit. Cases were reviewed by investigators and clinicians to identify: 1) the proportion of unscheduled RTED, 2) the proportion deemed clinically unnecessary and 3) the contribution of clinical practice pattern and system factors.

RESULTS

There were 2809 (7.3%) index visits associated with at least one RTED. Of these, 1983 (70.6%) were unscheduled, 784 (39.5%) were considered clinically unnecessary and 739 out of 784 medically unnecessary RTEDs (94.3%) were attributed to a mismatch between parental expectations and natural progression of disease that did not require Emergency Department (ED) reassessment or interventions. Eighty per cent of reviewed written discharge instructions lacked any anticipatory guidance around symptom range and duration and 21.2% contained instructions to return to the ED for signs and symptoms which do not require ED care. An administrative or system challenge was noted as the reason for the unnecessary and unscheduled RTED in 17.5%. In 3.4% of cases, nonemergency consultants were responsible for the disposition decision and discharge process.

CONCLUSIONS

Unscheduled unnecessary return visits to our ED contribute to a significant proportion of our annual volume. Providing discharge instructions that help families distinguish expected range and duration of symptoms from signs requiring ED care was identified as a potential strategy to impact the frequency of unscheduled RTED.

Seventy-two-hour emergency department revisits among adults with chronic diseases: a Saudi Arabian study

Background

Despite the increase in adult emergency department (ED) utilization in Saudi Arabia, no studies have evaluated the 72-hour revisits. This study estimates the rate of 72-hour ED revisits and identifies its reasons and predictive factors among adults with chronic diseases.

Patients and methods

A hospital-based retrospective study that included 24,206 ED discharges for adults with chronic diseases at the adult ED of King Abdulaziz Medical City, Riyadh between September 13, 2015 and July 29, 2017 was performed. We extracted data on demographic information, reasons for ED visits/revisits, health insurance coverage, weekend ED arrival, and mortality.

Results

A sample of 24,206 ED discharges for 19,697 adults with at least one chronic disease was included in the analysis. The rate of 72-hour revisits in this study population was high: 3,144/24,206 (13%) had the first revisit and 319/3,144 (10.1%) had the second ED revisit within 72 hours. Diseases of the circulatory (19%) and genitourinary (15.8%) systems were the major reasons for the first ED revisit. The adjusted relative rate (aRR) of 72-hour ED revisits was higher in adults with chronic diseases and aged ≥60 years (aRR=1.360, 95% CI: 1.41–1.83; P=0.001), patients of female gender (aRR=1.24, 95% CI: 1.09–1.41; P=0.001), patients with health insurance coverage (aRR=4.23, 95% CI: 2.60–6.90; P=0.001), patients arriving to ED on a weekend (aRR=2.13, 95% CI: 1.03–4.41; P=0.041), and new patients (aRR=1.47, 95% CI: 1.25–1.73; P=0.001).

Conclusion

The rate of 72-hour revisits is high among adults with chronic diseases. Advancing age, female gender, health insurance coverage, weekend ED arrival, and new patients are the important predictive factors of the high rate of 72-hour revisits. Continuous quality assessment and monitoring of factors related to patients are needed to reduce the frequency of early ED revisits after discharge.

Emergency department 72-hour revisits among children with chronic diseases: a Saudi Arabian study

BACKGROUND

Emergency Department (ED) revisits have often been used as an indicator of medical care quality. This study aimed to quantify the frequency of ED revisits within 72 h of discharge and identify its factors among children with chronic diseases.

METHODS

We designed a retrospective cohort study of children with at least one chronic disease who were also under 18 years of age and had attended and were discharged from the ED at King Abdullah Specialist Children's Hospital (KASCH-RD), Riyadh, Saudi Arabia between April 19, 2015 and July 29, 2017. The outcome measure was the frequency of ED revisits during a period of 72 h after discharge.

RESULTS

The study included 11,057 ED discharges of children with at least one chronic disease. Their revisit rate was 1211 (11%), with 83 (6.9%) having had a second ED revisit within 72 h of ED discharge. According to ICD-10 codes, the most common causes of ED revisits were respiratory, digestive, genitourinary, symptoms, and external causes. Factors of frequent ED revisits within 72 h were young age, institutional health insurance coverage, year of new health information system (2015), external causes, and genitourinary.

CONCLUSION

The rate of 72-h ED revisits after discharge of children with chronic diseases treated at KASCH-RD was relatively high, and was associated with young age, institutional health insurance coverage, year of a new health information system implementation, and external causes of ED visit. These study findings amplify the need for intervention to reduce the rate of early ED revisits among children with chronic diseases.

The French Emergency National Survey: A description of emergency departments and patients in France

INTRODUCTION

Some major changes have occurred in emergency department (ED) organization since the early 2000s, such as the establishment of triage nurses and short-track systems. The objectives of this study were to describe the characteristics of French EDs organization and users, based on a nationwide cross-sectional survey.

METHODS

The French Emergency Survey was a nationwide cross-sectional survey. All patients presenting to all EDs during a 24-hr period of June 2013 were included. Data collection concerned ED characteristics as well as patient characteristics.

RESULTS

Among the 736 EDs in France, 734 were surveyed. Triage nurses and short-track systems were respectively implemented in 73% and 41% of general EDs. The median proportion of patients aged > 75 years was 14% and median hospitalisation rate was 20%. During the study period, 48,711 patients presented to one of the 734 EDs surveyed. Among them, 7% reported having no supplementary health or universal coverage (for people with lower incomes). Overall, 50% of adult patients had been seen by the triage nurse in less than 5 minutes, 74% had a time to first medical contact shorter than one hour and 55% had an ED length of stay shorter than 3 hours.

CONCLUSION

The French Emergency Survey is the first study to provide data on almost all EDs in France. It underlines how ED organization has been redesigned to face the increase in the annual census. French EDs appear to have a particular role for vulnerable people: age-related vulnerability and socio-economic vulnerability with an over-representation of patients without complementary health coverage.

Risk Factors Associated With Emergency Department Return Visits Following Trauma System Discharge

OBJECTIVES

Little evidence exists in the pediatric trauma literature regarding what factors are associated with re-presentation to the hospital for patients discharged from the emergency department (ED).

METHODS

This was a retrospective cohort study of trauma system activations at a pediatric trauma center from June 30, 2007, through June 30, 2013, who were subsequently discharged from the ED or after a brief inpatient stay. Returns within 30 days were reviewed. χ, Student t test, and univariate logistical regression were used to compare predictive factors for those returning and not.

RESULTS

One thousand eight hundred sixty-three patient encounters were included in the cohort. Seventy-two patients (3.9%) had at least 1 return visit that was related to the original trauma activation. Age, sex, language, race/ethnicity, ED length of stay, arrival mode, level of trauma activation, and transfer from an outside hospital did not vary significantly between the groups. Patients with public insurance were almost 2 times more likely to return compared with those with private insurance (odds ratio, 1.92; 95% confidence interval, 1.11-3.35). Income by zip code was associated with the risk of a return visit, with patients in neighborhoods at less than the 50th percentile income twice as likely to return to the ED (odds ratio, 2.15; 95% confidence interval, 1.30-3.54).

CONCLUSIONS

Patients with public insurance and those from low-income neighborhoods were significantly more likely to return to the ED after trauma system activation. These data can be used to target interventions to decrease returns in high-risk trauma patients.

A Survey of Return Visits to the Pediatric Emergency Department: The Caretakers' Perspective

OBJECTIVE

Approximately 5% of children return to the emergency department within 72 hours of a first evaluation. Previous literature has focused on healthcare utilization and the use of return visits as a quality metric. The goal of this study was to quantify reasons for return visits from the caretaker perspective.

METHODS

Caretaker surveys were developed based on previously identified themes from focus groups. When considering reasons for return, multiple answers were allowed. Surveys were administered to a convenience sample of eligible caretakers who returned to the emergency department within 72 hours between June and August 2013. Caretakers were excluded if the return was scheduled or for an unrelated complaint.

RESULTS

Of the 306 eligible caretakers, 83 (27%) participated. A majority returned because of continued (92%) or worsening symptoms (70%). More than half returned because they did not know how to help their child at home (60%), they did not understand their child's illness (59%), and/or they did not expect the persistence of symptoms (58%). Overall, caretakers felt more testing (55%), treatments (45%), medications (41%), and information (28%) should have been provided at the initial visit. Caretakers of children admitted at the second visit were significantly more dissatisfied with care at the first visit (P = 0.05).

CONCLUSIONS

The most commonly reported reasons for pediatric return visits were continued symptoms and lack of illness understanding. We plan to use these data to develop targeted interventions to decrease the perceived need for return visits.

Risk of hospitalisation after early-revisit in the emergency department

AIM

Early-revisits are frequent in the paediatric emergency department (ED) setting, but few data are available about early-revisited patients. The aim of this study was to investigate the hospitalisation rate of a population of early-revisited patients and to detect if an early-revisited patient was at risk of a more severe disease.

METHODS

Between June 2014 and January 2015, we conducted a retrospective cohort study, considering all patients presented to the ED of a tertiary level children's hospital in Italy. We selected all patients who were revisited within 72 h from the initial visit (study cohort), while all other patients accessed in the same period were considered the control cohort. The two cohorts were compared for age, gender, triage category, hospitalisation rate, diagnosis at admission and hospital length of stay.

RESULTS

In the study period, we reviewed 10 750 visits, of which 430 (4%) were unplanned revisits for the same chief complaint within 72 h from the initial visit. Hospitalisation rate of early-revisited patients was significantly higher compared to control patients (8.4 vs. 2.9%). Hospitalisation rate increases in parallel with the number of revisits, but in many cases, it was not directly related to a worst triage category, neither to a longer hospital length of stay.

CONCLUSION

Early revisited patients in the ED had a significantly higher risk of hospitalisation, but this risk was only partially related to their clinical conditions.

Factors Determining Parents' Decisions to Bring Their Children to the Pediatric Emergency Department for a Minor Illness

Background

The number of children visiting Emergency Departments (EDs) is increasing in Lithuania; therefore, the aim of this study was to determine the factors influencing the parental decision to bring their child to the ED for a minor illness that could be managed in a primary healthcare setting, and to compare parents’ and medical professionals’ attitudes toward a child’s health status and need for urgent care.

Material/Methods

A prospective observational study was performed at the tertiary-level teaching Children’s Hospital in Vilnius. A total of 381 patients’ parents were interviewed using an original questionnaire based on Andersen’s behavioral model of healthcare utilization; in addition, the medical records of patients were reviewed to identify factors that might have an impact on parental decisions to bring their child to the ED for a minor health problem. The study participants were enrolled from October 1, 2013 to August 31, 2014. The urgency of medical care needed to be provided to the patients was evaluated by a tertiary-level triage system.

Results

Based on the assessment of the triage nurses, the need for emergency care to patients was distributed as follows: 298 patients (78.2%) needed non-urgent care and 83 patients (21.8%) needed urgent care. More than one-third (38.8%) of the parents reported that they came to the ED due to their child’s urgent care need and worsened child’s health; however, the opinion of ED professionals indicated only a fifth of patients required urgent care. Parents who brought their children to the ED without physician referral were five times more likely to visit the ED during evening hours and on weekends (OR=5.416; 95% CI, 3.259–8.99; p<0.001). The decision to come to the ED without visiting a primary care physician was made more often by parents with a higher income (OR=2.153; 95% CI, 1.167–3.97) and those who came due to children having rash (OR=4.303; 95% CI, 1.089–16.995) or fever (OR=3.463; 95% CI, 1.01–11.876). Older parents were 2.07 (95% CI, 1.1224–3.506) times more likely to evaluate their child’s health unfavorably than younger parents.

Conclusions

We identified predisposing, enabling, and need factors that influenced the parents’ decision to bring their child to the ED for minor health problems that could be managed by a primary care physician. Parents assessed their child’s condition more critically and thought that their child required urgent medical aid more frequently than healthcare professionals.

Comparison of Primary Care Provider Office Hours and Pediatric Emergency Department Return Visits

OBJECTIVE

The aim of this study was to evaluate the influence of primary care office hours of operation on 48-hour return visits (RVs) to a pediatric emergency department (ED). We compared characteristics of patients who return with those who follow up outpatient to determine the feasibility of opening off-hour clinics to decrease the RV rate.

METHODS

The study was a retrospective chart review of patients presenting to a pediatric ED for a 3-year period. A subset of patients with a hospital-affiliated primary care provider was evaluated to compare those with 48-hour ED RVs with those with office follow-up.

RESULTS

Patients with a hospital-affiliated primary care provider had 30,231 visits, of whom 842 had a 48-hour return (2.79%). A significant number (48.5%) of those who returned had seen their primary care doctor between emergency visits. The percentage of RVs occurring at night (55.7%) was slightly lower than the percentage of all visits occurring off hours (58.1%). Patients with more acute presentation at initial visit (emergency severity index level acuity 2, >20 orders placed) were more likely to follow up with their provider than return to the ED.

CONCLUSIONS

The findings from this study show no significant increase in RVs during the evening and overnight hours and many patients with outpatient follow-up before returning to the ED. Opening a clinic at our hospital during nontraditional hours would not likely significantly decrease RV rate.

Return visits to the pediatric emergency department: A multicentre retrospective cohort study

Objective

Return visits to the emergency department (RTED) for the same clinical complaint occur in 2.7% to 8.1% of children presenting to pediatric emergency departments (PEDs). Most studies examining RTEDs have focused solely on PEDs and do not capture children returning to other local emergency departments (EDs). Our objective was to measure the frequency and characterize the directional pattern of RTED to any of 18 EDs serving a large geographic area for children initially evaluated at a PED.

Methods

We conducted a retrospective cohort study of all visits to a referral centre PED between August 2012 and August 2013. We compared demographic variables between children with and without an RTED, measures of flow and disposition outcomes between the initial (index) visit and RTED, and between RTED to the original PED versus to other EDs in the community.

Results

Among all PED visits, 7.6% had an RTED within 7 days, of which 13% were to a facility other than the original PED. Children with an RTED had higher acuity and longer length of stay on their index visit. They were also more likely to be admitted on a subsequent visit than the overall PED population. RTED to the original PED had a longer waiting time (WT), length of stay, and more frequently resulted in hospitalization than RTED to a general ED.

Conclusions

A significant proportion of RTED occur at a site other than where the original ED visit occurred. Examining RTED to and from only PEDs underestimates its burden on emergency health services.

Predicting return visits to the emergency department for pediatric patients: Applying supervised learning techniques to the Taiwan National Health Insurance Research Database

BACKGROUND AND OBJECTIVE

Return visits (RVs) to the emergency department (ED) consume medical resources and may represent a patient safety issue. The occurrence of unexpected RVs is considered a performance indicator for ED care quality. Because children are susceptible to medical errors and utilize considerable ED resources, knowing the factors that affect RVs in pediatric patients helps improve the quality of pediatric emergency care.

METHODS

We collected data on visits made by patients aged ≤18years to EDs from the National Health Insurance Research Database. The outcome of interest was a RV within 3days of the initial visit. Potential factors were categorized into demographics, medical history, features of ED visits, physician characteristics, hospital characteristics, and treatment-seeking behavior. A multivariate logistic regression was used to identify independent predictors of RVs. We compared the performance of various data mining techniques, including Naïve Bayes, classification and regression tree (CART), random forest, and logistic regression, in predicting RVs. Finally, we developed a decision tree to stratify the risk of RVs.

RESULTS

Of 125,940 visits, 6,282 (5.0%) were followed by a RV within 3 days. Predictors of RVs included younger age, higher acuity, intravenous fluid, more examination types, complete blood count, consultation, lower hospital level, hospitalization within one week before the initial visit, frequent ED visits in the past one year, and visits made in Spring or on Saturdays. Patients with allergic diseases and those underwent ultrasound examination were less likely to return. Decision tree models performed better in predicting RVs in terms of area under curve. The decision tree constructed using the CART technique showed that the number of ED visits in the past one year, diagnosis category, testing of complete blood count, and age were important discriminators of risk of RVs.

CONCLUSIONS

We identified several factors which are associated with RVs to the ED in pediatric patients. The knowledge of these factors may help assess risk of RVs in the ED and guide physicians to reevaluate and provide interventions to children belonging to the high risk groups before ED discharge.

Parental Language and Return Visits to the Emergency Department After Discharge

OBJECTIVE

Return visits to the emergency department (ED) are used as a marker of quality of care. Limited English proficiency, along with other demographic and disease-specific factors, has been associated with increased risk of return visit, but the relationship between language, short-term return visits, and overall ED use has not been well characterized.

METHODS

This is a planned secondary analysis of a prospective cohort examining the ED discharge process for English- or Spanish-speaking parents of children aged 2 months to 2 years with fever and/or respiratory illness. At 1 year after the index visit, a standardized chart review was performed. The primary outcome was the number of ED visits within 72 hours of the index visit. Multivariable logistic regression was used to examine the relative importance of predictor variables and adjust for confounders.

RESULTS

There were 202 parents eligible for inclusion, of whom 23% were Spanish speaking. In addition, 6.9% of the sample had a return visit within 72 hours. After adjustment for confounders, Spanish language was associated with return visit within 72 hours (odds ratio, 3.49; 95% confidence interval, 1.02-11.90) but decreased risk of a second visit within the year (odds ratio, 0.28; 95% confidence interval, 0.12-0.66).

CONCLUSION

Spanish-speaking parents are at an increased risk of 72-hour return ED visit but do not seem to be at increased risk of ED use during the year after their ED visit.

Development of a Patient-centered Outcome Measure for Emergency Department Asthma Patients

BACKGROUND

Measuring outcomes of emergency care is of key importance, but current metrics, such as 72-hour return visit rates, are subject to ascertainment bias, incentivize overtesting and overtreatment at initial visit, and do not reflect the full burden of disease and morbidity experienced at home following ED care. There is increasing emphasis on including patient-reported outcomes, but the existing patient-reported measures have limited applicability to emergency care.

OBJECTIVE

The objective was to identify concepts for inclusion in a patient-reported outcome measure for ED care and assess differences in potential concepts by health literacy.

METHODS

A three-phase qualitative study was completed using freelisting and semistructured interviewing for concept identification, member checking for concept ranking, and cognitive interviewing for question development. Participants were drawn from three tertiary care EDs. Parents of patients (pediatric) or patients (adult) with asthma completed a demographic survey and an assessment of health literacy. Phase 1 participants also completed a freelisting exercise and qualitative interview regarding the definition of success following ED discharge. Phase 2 participants completed a member checking survey based on concepts identified in Phase 1. Phase 3 was a pilot of trial questions based on the highest-ranked concepts from Phase 2.

RESULTS

Phase 1 enrolled 22 adult patients and 37 parents of pediatric patients. Phase 2 enrolled 41 adult patients and 200 parents. Phase 3 involved 15 parents. Across all demographic/literacy groups, Phase 1 participants reported return to usual activity and lack of asthma symptoms as the most important markers of success. In Phase 2, symptom improvement, medication use and access, and asthma knowledge were identified as the most important components of the definition of post-ED discharge success. Phase 3 resulted in five questions for the proposed measure.

CONCLUSIONS

A stepwise qualitative process can identify, rank, and formulate questions based on patient-identified concepts for inclusion in a patient-reported outcome measure for ED discharge. The four key concepts identified for inclusion: symptom improvement, medication access, correct medication use, and asthma knowledge are not measured by existing quality metrics.

Unplanned reattendances at the paediatric emergency department within 72 hours: a one-year experience in KKH

INTRODUCTION

Unscheduled reattendances at the paediatric emergency department may contribute to overcrowding, which may increase financial burdens. The objectives of this study were to determine the rate of reattendances and characterise factors influencing these reattendances and hospital admission during the return visits.

METHODS

Medical records of all patients who attended the emergency department at KK Women's and Children's Hospital, Singapore, from 1 June 2013 to 31 May 2014 were retrospectively reviewed. We collected data on patient demographics, attendance data and clinical characteristics. Planned reattendances, recalled cases, reattendances for unrelated complaints and patients who left without being seen were excluded. A multivariate analysis was conducted to determine the odds ratio of variables associated with hospital admission for reattendances.

RESULTS

Of 162,566 children, 6,968 (4.3%) returned within 72 hours, and 2,925 (42.0% of reattendance group) were admitted on their return visits. Children more likely to reattend were under three years of age, Chinese, triaged as Priority 2 at the first visit, and were initially diagnosed with respiratory or gastrointestinal conditions. However, children more likely to be admitted on their return visits were over 12 years of age, Malay, had a higher triage acuity or were uptriaged, had the presence of a comorbidity, and were diagnosed with gastrointestinal conditions.

CONCLUSION

We identified certain subgroups in the population who were more likely to be admitted if they reattended. These findings would help in implementing further research and directing strategies to reduce potentially avoidable reattendances and admissions.

Emergency Department Return Visits Within a Large Geographic Area

BACKGROUND

Return visits to the emergency department (RTED) contribute to overcrowding and may be a quality of care indicator. Previous studies focused on factors predicting returns to and from the same center. Little is known about RTEDs across a range of community and specialty hospitals within a large geographic area.

OBJECTIVE

We sought to measure the frequency of pediatric RTEDs and describe their directional pattern across centers in a large catchment area.

METHODS

We conducted a multicenter, retrospective cross-sectional study of pediatric emergency visits in the Vancouver lower mainland within 1 year. Visits were linked across study sites, including one pediatric quaternary care referral center and 17 sites ranging from large regional centers to smaller community emergency departments (EDs). Returns were defined as subsequent visits to any site with a compatible diagnosis within 7 days of an index visit.

RESULTS

Among a total of 139,278 index ED visits by children, 12,133 (8.7% [95% confidence interval 8.6-8.9%]) were associated with 14,645 return visits to an ED. Three quarters of all index visits occurred at a general ED center, of which 8.9% had at least one RTED and 22% of these returns occurred at the pediatric ED (PED). Among PED index visits, 8.2% had at least one RTED and 13.6% of these returned to a general center. Overall, 38.9% of all RTEDs occurred at the PED. Multivariate regression did not identify any statistically significant association between ED crowding measures and likelihood of RTEDs.

CONCLUSIONS

Compared to single-center studies, this study linking hospitals within a large geographic area identified a higher proportion of RTEDs with a disproportionate burden on the PED.

Unscheduled return visits to a pediatric emergency department

BACKGROUND AND OBJECTIVE

Return visits (RVs) to a pediatric emergency department (ED) within a short period after discharge have an influence on overcrowding of the ED and reveal some weaknesses of the health care system. The aim of this study was to determine the rate of RVs and factors related to RVs to the pediatric ED in Lithuania.

MATERIALS AND METHODS

A retrospective study in an urban, tertiary-level teaching hospital was carried out. Electronic medical records of all patients (n=44097) visiting the ED of this hospital between 1 January and 31 December 2013 were analyzed. Demographic and clinical characteristics of patients who return to the ED within 72h and those who had not visited the ED were compared. Factors associated with RVs were determined by multivariable logistic regression.

RESULTS

Of the overall ED population, 33889 patients were discharged home after the initial assessment. A total of 1015 patients returned to the ED within 72h, giving a RV rate of 3.0%. Being a 0-7-year old, visiting the ED during weekdays, having a GP referral, receiving of laboratory tests and ultrasound on the initial visit were associated with greater likelihoods of returning to the ED. Patients who arrived to the ED from 8:01a.m. to 4:00p.m. and underwent radiological test were less likely to return to the ED within 72h. Diseases such as gastrointestinal disorders or respiratory tract/earth-nose-throat (ENT) diseases and symptoms such as fever or pain were significantly associated with returning to the ED. The initial diagnosis corresponded to the diagnosis made on the second visit for only 44.1% of the patients, and the highest rate of the congruity in diagnosis was for injuries/poisoning, surgical pathologies (77.2%) and respiratory tract diseases (76.9%).

CONCLUSIONS

RVs accounted for only a small proportion of visits to the ED. RVs were more prevalent among younger patients and patients with a GP referral as well as performed more often after discharging from the ED in the evening and at night.

Caretakers' Perspectives on Return Pediatric Emergency Department Visits: A Qualitative Analysis of Focus Groups

OBJECTIVES

Approximately 5% of pediatric patients return to the emergency department (ED) within 72 hours of initial evaluation. The goal of this study was to identify reasons for return visits from the caretaker perspective.

METHODS

Two parent focus groups were conducted in November 2012. Parents were excluded from participation if the return visit was unrelated to the initial visit or the child was asked to return (e.g., wound check). The focus groups were audiotaped, transcribed, and analyzed using a thematic content analysis approach.

RESULTS

A total of 13 parents participated. Children were 10 months to 11 years of age (median, 3.1 years). Primary symptoms and diagnoses were related to respiratory (n = 6); gastrointestinal (n = 2); dermatologic (n = 2); musculoskeletal (n = 2); and ear, nose, throat and mouth diseases (n = 1). Return visits occurred 12 to 50 hours (median, 24 hours) after the initial visit. Reasons for return visits were divided into 4 domains: (1) the caretaker's response to the initial visit (e.g., dissatisfaction with medical staff, medical care, or information provided), (2) the child's illness (e.g., continued, worsening, or concerning symptoms), (3) the nature of the ED itself (e.g., subspecialist availability, convenient hours), and (4) follow-up care (e.g., lack of appointments with primary physicians or subspecialists).

CONCLUSIONS

Several of the reasons parents identify for return visits are within the locus of control of the ED, and several could be addressed by improving regional health care coordination. Surveys based on these themes will quantitate the reasons for return visits and prioritize future strategies to address the perceived need for return visits.

Return to the emergency department after ventricular shunt evaluation

OBJECT Patients with CSF shunts are medically complex and frequently present to the emergency department (ED) with suspected shunt malfunction. After adequate evaluation in the ED and proper disposition, some patients return to the ED within a short period of time. In this study, the authors examined the reasons for ED revisits within 7 days of the index ED visit to discern possible preventable returns. METHODS There were 3080 index ED visits made by patients with shunted hydrocephalus between 2010 and 2013. Index ED visits preceded by another ED visit or neurosurgical procedure within 60 days were excluded. Index ED visits for reasons unrelated to shunt function and those that led directly to admissions and shunt revision surgeries were also excluded. The remaining 1509 ED visits were eligible for analysis in this study. Final dispositions from the index ED visit included home (1176 cases), admission to the neurosurgery service for observation (134 cases), and admission to other services (199 cases). Subsequent events within 7 days, including ED revisits, hospital admissions, and shunt-related surgery were recorded, and reasons for the ED revisits were categorized based on whether the visit was related to shunt function concerns. Clinical and socioeconomic factors were analyzed for their association with ED revisits by using statistical methods. RESULTS Of the 1176 patients discharged home from the ED after shunt function evaluation, 101 (8.6%) returned to the ED within 7 days. Of the 134 patients admitted to the neurosurgery service for observation only, 8 (6.0%) returned to the ED within 7 days of discharge. Of the 199 patients admitted to hospital services other than neurosurgery, 13 (6.5%) returned to the ED within 7 days of discharge. The reasons for ED revisits vary (total of 122 visits combining the 3 groups), but at least 60% of the revisits were clearly unrelated to shunt function. A younger age, daytime arrival to the ED, and living within the metropolitan area were identified as risk factors for ED revisits. CONCLUSIONS Children with CSF shunts are medically complex and use ED services often. After an index ED visit at which shunt function was deemed to be the chief concern, the purpose of the subsequent return to the ED within 7 days was often for complaints unrelated to shunt function. Caution is warranted when attempting to classify these complex patients as having potential preventable return-to-system events.

Emergency Department Revisits by Urban Immigrant Children in Canada: A Population-Based Cohort Study

OBJECTIVES

To examine the relationship between family immigrant status and unscheduled 7-day revisits to the emergency department (ED) and to test this relationship within subgroups of immigrants by visa class (family, economic, refugee), native tongue on landing in Canada, and region of origin.

STUDY DESIGN

Population-based cohort study that used multiple linked health administrative and demographic datasets of landed immigrant and nonimmigrant children (<18 years) in urban Ontario who visited an ED and were discharged between April 2003 and March 2010. Logistic regression was used to model the odds of 7-day ED revisits with family immigrant status, with adjustment for patient and ED characteristics.

RESULTS

Of 3,322,901 initial visits to the ED, 249,648 (7.5%) resulted in a 7-day revisit. There was no significant association of immigrant status with either ED revisits or poor revisit outcomes (greater acuity visit or need for admission) in the adjusted models. Within immigrants, the odds of revisit were not associated with immigrant classes or region of origin; however, immigrants whose native tongue was not English or French had a slightly greater odds of revisiting the ED (aOR 1.05; 95% CI 1.01, 1.09). Significant predictors of revisits included younger age, greater triage acuity score, greater predilection for using an ED, daytime shifts, and greater deprivation index.

CONCLUSIONS

Immigrant children are not more likely to have short-term revisits to the ED, but there may be barriers to care related to language fluency that need to be addressed. These findings may be relevant for improving translation services in EDs.

Accuracy of diagnosis codes to identify febrile young infants using administrative data

BACKGROUND

Administrative data can be used to determine optimal management of febrile infants and aid clinical practice guideline development.

OBJECTIVE

Determine the most accurate International Classification of Diseases, Ninth Revision (ICD-9) diagnosis coding strategies for identification of febrile infants.

DESIGN

Retrospective cross-sectional study.

SETTING

Eight emergency departments in the Pediatric Health Information System.

PATIENTS

Infants aged <90 days evaluated between July 1, 2012 and June 30, 2013 were randomly selected for medical record review from 1 of 4 ICD-9 diagnosis code groups: (1) discharge diagnosis of fever, (2) admission diagnosis of fever without discharge diagnosis of fever, (3) discharge diagnosis of serious infection without diagnosis of fever, and (4) no diagnosis of fever or serious infection.

EXPOSURE

The ICD-9 diagnosis code groups were compared in 4 case-identification algorithms to a reference standard of fever ≥100.4°F documented in the medical record.

MEASUREMENTS

Algorithm predictive accuracy was measured using sensitivity, specificity, and negative and positive predictive values.

RESULTS

Among 1790 medical records reviewed, 766 (42.8%) infants had fever. Discharge diagnosis of fever demonstrated high specificity (98.2%, 95% confidence interval [CI]: 97.8-98.6) but low sensitivity (53.2%, 95% CI: 50.0-56.4). A case-identification algorithm of admission or discharge diagnosis of fever exhibited higher sensitivity (71.1%, 95% CI: 68.2-74.0), similar specificity (97.7%, 95% CI: 97.3-98.1), and the highest positive predictive value (86.9%, 95% CI: 84.5-89.3).

CONCLUSIONS

A case-identification strategy that includes admission or discharge diagnosis of fever should be considered for febrile infant studies using administrative data, though underclassification of patients is a potential limitation.

Predicting Factors and Risk Stratification for Return Visits to the Emergency Department Within 72 Hours in Pediatric Patients

OBJECTIVES

A return visit (RV) to the emergency department (ED) is usually used as a quality indicator for EDs. A thorough comprehension of factors affecting RVs is beneficial to enhancing the quality of emergency care. We performed this study to identify pediatric patients at high risk of RVs using readily available characteristics during an ED visit.

METHODS

We retrospectively collected data of pediatric patients visiting 6 branches of an urban hospital during 2007. Potential variables were analyzed using a multivariable logistic regression analysis to determine factors associated with RVs and a classification and regression tree technique to identify high-risk groups.

RESULTS

Of the 35,435 visits from which patients were discharged home, 2291 (6.47%) visits incurred an RV within 72 hours. On multivariable analysis, younger age, weekday visits, diagnoses belonging to the category of symptoms, signs, and ill-defined conditions, and being seen by a female physician were associated with a higher probability of RVs. Children younger than 6.5 years who visited on weekdays or between midnight and 8:00 AM on weekends or holidays had the highest probability of returning to the ED within 72 hours.

CONCLUSIONS

Our study reexamined several important factors that could affect RVs of pediatric patients to the ED and identified high-risk groups of RVs. Further intervention studies or qualitative research could be targeted on these at-risk groups.

Emergency Department Return Visits Resulting in Admission: Do They Reflect Quality of Care?

Prior studies have suggested that emergency department (ED) return visits resulting in admission may be a more robust quality indicator than all 72-hour returns. The objective was to evaluate factors that contribute to admission within 72 hours of ED discharge. Each return visit resulting in admission was independently reviewed by 3 physicians. Analysis was by descriptive statistics. Of 45 071 ED discharges, 4.1% returned within 72 hours; 0.96% returned for related reasons and were admitted to wards (91.2%), intensive care units (6.5%), or operating rooms (1.2%). Management was acceptable in 92.6%, suboptimal in 7.4%. Admissions were illness (94.9%), patient (1.6%), and physician related (3.5%). Almost all admissions within 72 hours after ED discharge are illness related, including all intensive care unit admissions and the majority of operating room admissions. Deficiencies in ED care are rarely the reason for admission on return. ED return visits resulting in admission may not be reflective of ED quality of care.